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OTDNet Webinar
22nd May 2013
Today
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8:30 – Malcolm has a ‘smokers cough’
8:45 – Ed presents with shortness of breath
9:00 – Golriz is feeling generally unwell
9:15 - Susan is experiencing chest pain
9:30 – Gabriella can’t sleep
9:45 – John has coughed up some blood
10:00 - End
Malcolm has a ‘smokers cough’
You are consulted for the first time by Malcolm,
aged 61, who has noticed he is becoming
increasingly more short of breath when climbing
stairs. He has smoked 20 cigarettes a day since the
age of 19.
He has a morning cough producing a small amount
of white sputum, which he attributes to a ‘smokers
cough’.
Based on a detailed history and
examination, you make a provisional diagnosis of
COPD.
Malcolm has a ‘smokers cough’
How can you rapidly assess a patient’s degree of
breathlessness and the impact it has on their
daily life?
The functional limitation from breathlessness due to COPD
can be quantified by using the breathlessness scale, which is
a grading system developed originally in the UK by the
Medical Research Council.
Malcolm has a ‘smokers cough’
How can your provisional diagnosis of COPD be
confirmed?
Spirometry is the gold standard for diagnosing,
assessing and monitoring COPD.
Malcolm’s spirometry
is shown in Figure 1.
This shows:
FEV1 = 65% predicted
FEV1 /FVC ratio = 66%
10% improvement in
FEV1 post
bronchodilator
Does Malcolm have
COPD?
Yes.
COPD is defined by a post-bronchodilator
• FEV1 /FVC ratio is <70%
Airflow limitation is not fully-reversible, when
the ratio is <70% AND
• FEV1 is <80% of the predicted value
Malcolm has a ‘smokers cough’
Malcolm is surprised and worried by the
diagnosis. He wants to know how he can treat
his COPD and how he can prevent his condition
from getting worse.
Malcolm has a ‘smokers cough’
What is the single (1) most effective measure to
reduce decline in lung function and prevent
future decline in Malcolm’s COPD?
In order to treat Malcolm, what must you know
about his COPD?
Only complete smoking cessation slows decline in
lung function. Spirometry is of limited use in
predicting whether a patient is likely to quit in the
future. A study of primary care evaluated the
impact of telling patients their estimated lung age as
an incentive to quit smoking. Verified quit rates at
12 months were 13.6% in the lung age group and
6.4% in the raw FEV group – NNT = 14.
To treat Malcolm effectively we need to classify his
COPD severity.
Source: www.copdx.org.au
Malcolm has a ‘smokers cough’
You diagnose Malcolm as having mild, stable
COPD. What is your recommendation regarding
treatment for Malcolm?
Ed presents with shortness of breath
Ed, aged 78, is well known to your practice. He has a
history of COPD, stable angina, atrial fibrillation,
hypertension and hypercholesterolaemia.
His
medications include tiotropium, salbutamol, verapamil,
warfarin, ramipril and atorvastatin. He has no allergies.
Ed has smoked since his late teens, averaging 20
cigarettes a day. He lives with his wife Susan in a
retirement village, is a retired accountant, plays golf twice
a week and has 5 grandchildren.
Ed is your first patient and he walks slowly from the
waiting room, sits down and coughs intermittently. He
takes a few minutes to gather his breath.
Ed presents with shortness of breath
He has been unwell for the last 2 days with a runny nose,
cough productive of yellow sputum and decreasing
exercise tolerance. He was unable to sleep lying flat, but
managed when propped up on a few pillows. He hasn’t
had any fevers and has not had any chest pain,
haemoptysis, or ankle swelling.
Examination shows that Ed is thin and has mild
respiratory distress. He is afebrile, HR 90 (irregular), RR
22, BP 140/80mmHg.
Ed has reduced air entry
throughout the chest, with scattered expiratory wheeze
and prolonged expiratory phase. His JVP is normal and
there is no peripheral oedema.
Ed presents with shortness of breath
What is your single (1) most likely diagnosis?
List two (2) differential diagnoses.
Ed is likely to have an exacerbation of his COPD. This
is supported by his PMHx, presenting symptoms,
and examination findings.
Other differential diagnoses to consider include CCF,
pneumonia, and myocardial ischaemia.
Ed presents with shortness of breath
List three (3) common precipitating causes.
Common precipitants include:
- Infection (60-80% of exacerbations); common bacterial
causes include Haemophilus influenzae, Streptococcus
pneumonia & Moraxella catarrhalis. Common viral
causes include influenza, parainfluenza, coronavirus and
rhinovirus.
- Non-infectious causes (20-40% of exacerbations); heart
failure, PE, pneumothorax and non-pulmonary infections.
- Precipitating and environmental factors such as cold air,
air pollution, allergens, ongoing smoking and nonadherence to prescribed medication.
Ed presents with shortness of breath
What investigations you would
requesting for Ed? List up to four (4).
consider
Potential investigations include
- Bloods: FBC; WCC ?infection, Hb ?anaemia,
pre-treatment UEC/LFT, Inflammatory markers
- Spirometry (to quantify the degree of
obstruction)
- ECG (known AF/cardiac risk factors for AMI)
- CXR (look for pneumonia/CCF/pnemothorax)
Ed presents with shortness of breath
What is your initial treatment? List, in note form
only, three (3) principles of initial
management.
Initial treatment should include;
- Short-acting bronchodilators (inhaled β2 agonists such as
salbutamol or terbutaline). These are recommended as first
line treatment, however some patients may respond better
to inhaled anticholinergics such as ipratropium bromide.
Note – a powdered metered dose inhaler (MDI) with spacer is
equally effective as nebulisation and is cheaper, more
portable, as well as reducing the risk of side effects (by
delivering lower total dose of medication)
- Doses should be repeated PRN
- Salbutamol 100mcg (up to 10 inhalations)
- Terbutaline 50mcg (1-2 inhalations)
- Ipratropium bromide 21mcg (up to 6 inhalations)
- The patient should seek medical attention if medication is
required more frequently than 3hrly
Initial treatment should include;
- Oral corticosteroids; these should be prescribed if there is
significant breathlessness as they shorten the duration of illness
and reduce the likelihood of treatment failure.
- Recommended dose of oral prednisolone is 30-50mg daily
(mane) for 7-14 days.
Note – The duration of oral steroid therapy is not well established,
however the above regimen is commonly used. Longer courses
add no further benefit and have higher risk of adverse effects. If
the course of therapy is shorter than 14 days, the prednis(ol)one
may be ceased without tapering.
- Oral antibiotics; current therapeutic guidelines are
- Amoxicillin 500mg TDS for 5/7 OR
- Doxycycline 100mg BD for 5/7
Macrolides
(roxithromycin,
clarithromycin,
erythromycin,
azithromycin) are often ineffective, are more likely to result in
early relapse and interact with warfarin.
Ed presents with shortness of breath
You send Ed home with instructions on how to
administer salbutamol, oral steroids and
antibiotics. At 4:30pm his wife calls your
practice and tells you that over the last 2hrs Ed
has become increasingly breathless, is coughing
‘non-stop’, and appears to be increasingly
confused.
Ed presents with shortness of breath
You advise Susan that Ed needs to present to
hospital. What further treatment may be given
both on the way to hospital, and in hospital?
Ed may be treated with nebulised bronchodilators and
possibly intravenous steroids. Titrated oxygen therapy by
nasal cannulae has recently been shown to be superior to high
flow oxygen in the pre-hospital setting.
In hospital, Ed is likely to have CXR, ECG and ABG to screen for
hypercapnia and respiratory acidosis.
Specific therapy would include titrated oxygen therapy (aiming
for SaO2 of 90-92%), inhaled bronchodilators, corticosteroids,
and antibiotics and the dose and route of administration
would be guided by the severity of the illness.
Non-invasive ventilation is useful in the setting of respiratory
acidosis and has been shown to reduce mortality and the need
for intubation.
Occasionally, intubation and ventilation may be required if
BiPAP is ineffective or contraindicated.
Golriz is feeling generally unwell
Golriz, aged 18y, is a university student. She
presents to your practice with a sudden onset of
fever, sore throat, dry cough, generalised myalgia,
weakness, and mild headache. She is a non-smoker
and has no relevant past medical history.
On examination she is alert and orientated, looks
mildly unwell and is flushed. She has a temperature
of 39°C (tympanic), HR 100, BP 115/70mmHg and
RR 16. Golriz has no signs of meningism and her
chest is clear. You have seen several other patients
recently with similar symptoms.
Golriz is feeling generally unwell
What is the single (1) MOST LIKELY diagnosis?
What are three (3) possible differential diagnoses?
It is likely Golriz has an influenza-like illness. The
combination of respiratory symptoms with
systemic symptoms of fever, myalgia and
headache support a clinical diagnosis of influenzalike illness.
The differentials include the common cold,
pneumonia, invasive meningococcal disease and
meningitis due to other causes
Golriz is feeling generally unwell
Which viruses are responsible for seasonal
influenza?
Which strain of virus was/is responsible for
swine flu?
List three (3) additional viruses that can cause
an influenza-like illness.
Seasonal influenza is caused by influenza A and B.
Between 2009-2010 there was an outbreak of
influenza caused by an H1N1 influenza A virus
(swine flu). During this epidemic the rate of
infection was highest in those aged 18-24 (>50% of
cases). Infection in people >65yo was uncommon
because of pre-existing immunity from exposure to
anti-genically similar viruses.
Other viruses known to causes influenza-like illness
include respiratory syncitial virus, rhinovirus,
adenovirus, parainfluenza and human coronavirus.
Golriz is feeling generally unwell
Following your clinical provisional diagnosis,
Golriz requests treatment with antiviral
medication.
Golriz is feeling generally unwell
What is your advice regarding this request?
Studies have demonstrated an average reduction in symptom
duration of between 12-72hrs if treatment with antiviral
medication (neuraminidase inhibitors) is initiated within 24hrs
of onset of symptoms, and a reduction in the rate of
complications of influenza.
Therapeutic Guidelines (Antibiotic) recommends treatment of
those from high-risk groups, who present early with severe
symptoms.
In general the decision to treat depends on the likelihood of
influenza, time since onset of symptoms and likely benefits of
treatment based on age and comorbidities and the potential
for transmission to others.
You could advise Golriz that antivirals are not necessarily
indicated given that she is relatively young, usually healthy
and now >48hrs since the onset of her symptoms.
Golriz is feeling generally unwell
List four (4) groups of patients that are at highrisk of complications from influenza, and so who
should be considered for antiviral agents.
• Pregnant women
• The morbidly obese
• Those with underlying chronic disease, especially
asthma/respiratory disease and diabetes
• The immunosuppressed
• Homeless people
• Nursing home residents
• Indigenous Australians
• The extremes of age (>65 and <5)
• Those requiring hospitalisation
• Those with established complications e.g. pneumonia
• Healthcare workers
Golriz is feeling generally unwell
Golriz informs you that her sister is 18weeks
pregnant and she had planned to visit her this
weekend.
Golriz is feeling generally unwell
How is influenza spread and how long will Golriz
be shedding the virus?
Transmission is via respiratory droplets and potentially
with contaminated fomites. Immunocompetent adults
shed the virus for an average of 5 days, which includes
1-2 days during the 1-4 day incubation period. The
duration of shedding may be increased up to 10 days in
immunocompromised patients.
Golriz should avoid visiting her sister until 24hrs after
her fever has subsided, and at least 7 days as elapsed
since her respiratory symptoms commenced.
In general, prophylaxis with antiviral medication can be
considered for close contacts of proven cases,
particularly for those at higher risk of the complications
of influenza.
Golriz is feeling generally unwell
List two (2) potential complications of influenza.
Pneumonia is the most common complication and can
be either primary viral pneumonia or secondary
bacterial pneumonia. Secondary bacterial pneumonia
accounts for approximately 25% of all influenza deaths.
The most common organisms are Strep pneumoniae,
Staph aureus & haemophilus influenzae.
Neurological complications include encephalitis,
transverse myelitis, aseptic meningitis and GuillainBarré syndrome.
Myocarditis and pericarditis have also been reported.
Rhabdomyolysis and myositis are most commonly seen
in children.
Susan is experiencing chest pain
Susan, aged 32, is an office worker who
complains of sudden onset, right-sided, sharp
chest pain approximately 2hr ago.
She has no past medical history, takes no regular
medications and has been well recently. Susan
is a non-smoker.
You suspect that Susan may have developed a
spontaneous pneumothorax.
Susan is experiencing chest pain
List two (2) pieces of information on history that
would you seek from Susan that could support
your diagnosis of a pneumothorax?
Susan has dyspnoea and pleuritic chest pain,
which are common symptoms of pneumothorax.
You could ask the following, which would support
the working diagnosis of a pneumothorax
– Do you smoke?
– Do you have underlying lung disease – known bullae,
asthma, tuberculosis, cystic fibrosis?
– Do you use drugs such as marijuana or cocaine?
– Have you had a previous spontaneous
pneumothorax?
Susan is experiencing chest pain
List two (2) findings on examination that would
be consistent with a diagnosis of pneumothorax?
Findings on physical examination consistent with
pneumothorax include:
– Reduced or absent breath sounds on the affected side
– Hyper-resonance to percussion on the affected side
Less common findings include:
– Subcutaneous emphysema
– Unilateral chest enlargement
– Reduced excursion of the hemithorax with the
respiratory cycle
Signs of a tension pneumothorax include distended
neck veins, hypotension and cyanosis
Examination may be normal. This does NOT exclude
pneumothorax
Susan is experiencing chest pain
How do you classify pneumothoraces?
What is the single (1) most appropriate
investigation for Susan?
Pneumothoraces are classified as spontaneous or
traumatic
Spontaneous pneumothoraces are further divided
into primary or secondary on the basis of whether
the patient has clinically apparent lung disease
Susan has no known underlying pathology – she has
a primary spontaneous pneumothorax.
The single most appropriate investigation is CXR.
What does Susan’s CXR show?
Susan has a right-sided pneumothorax. There are
no radiological signs of tension i.e. the
mediastinum remains midline.
There are no rib fractures and no subcutaneous
emphysema. The lung fields are clear, suggesting
no obvious underlying lung pathology.
Susan is experiencing chest pain
Susan is clinically stable. You inform her of the
diagnosis and she wants to know about her
treatment options.
Susan is experiencing chest pain
What two variables determine the treatment for
spontaneous pneumothoraces?
How would you manage Susan’s pneumothorax?
Management of spontaneous PTX depends on size and
associated symptoms.
High-flow oxygen should be administered via Hudson mask as
early as possible to aide resorption
A 2cm PTX on CXR = 50% loss of lung volume.
A conservative approach is preferred and usually possible for
small-moderate PTX without symptoms (<2cm)
Large PTX (>2cm) should be aspirated either via needle
aspiration or catheter aspiration. Catheters may be ‘small bore’
or ‘large bore’. Small bore catheters are inserted via the
Seldinger technique. Larger catheters are inserted through a
surgically created tract, either through the 5th intercostal space
in the anterior axillary line, or the 2nd intercostal space in the
mid-clavicular line.
Larger catheters are more rigid, less likely to block and can have
suction applied to them more successfully which is useful for
those with underlying lung disease where the lung is less able to
re-expand, or where there is persistent air leak through pleural
injury that prevents lung expansion without suction.
Symptomatic PTX, or patients who are clinically unstable should
be managed with insertion of an intercostal catheter.
Small PTX that are being managed conservatively, or drained are
generally observed for 3-6hrs and if a rpt CXR confirms no
progression then patients can be discharged. A rpt CXR as an
outpatient should be performed in 2 weeks to ensure resolution
and patients should return to the ED if symptoms deteriorate.
Susan is experiencing chest pain
While you are explaining treatment options
Susan suddenly becomes more short of breath,
clammy, cyanosed and hypotensive. She has no
breath sounds audible throughout the entire
right hemithorax and you suspect she has
developed a tension pneumothorax.
Susan is experiencing chest pain
What is the immediate management for a
suspected tension pneumothorax in an unstable
patient?
- Immediate decompression
The largest bore IV catheter available should be
inserted in the second intercostal space in the
mid-clavicular line to release the air under
tension. The catheter should be left in situ until a
functioning intercostal catheter can be inserted.
Susan is experiencing chest pain
Susan recovers in hospital and comes to see you
a week later. She wants to discuss her upcoming
holiday plans. Susan had been planning a trip to
Thailand in the next month, and she is a keen
scuba-diver.
Susan is experiencing chest pain
What advice should you give Susan about her
intended trip and scuba diving?
Air travel should be avoided for 6 weeks following a
CXR that confirms resolution of the pneumothorax.
Scuba diving should be discouraged permanently
unless a definitive prevention strategy – such as
pleurodesis/pleurectomy has been performed.
Divers who wish to continue should be reviewed by
a thoracic surgeon for ongoing management and
advice regardless of the type or size of the
pneumothorax
Gabriella can’t sleep
Gabriella, aged 55, is a seamstress who presents
with a 4-yr history of difficulty initiating and
maintaining sleep resulting in daytime tiredness
and lowered mood.
Her symptoms have
gradually increased in severity and are
significantly affecting her quality of life.
Gabriella has no significant past medical history,
is on no regular medications, doesn’t smoke,
and drinks alcohol occasionally. She is active,
exercises regularly and often volunteers to
support local community groups.
Gabriella can’t sleep
List two (2) possible causes for Gabriella’s
presentation.
Insomnia is a common problem with an estimated prevalence of
5% in Australia. Peri-and post-menopausal women appear to be
particularly at risk with 25% of women aged 50-64 complaining of
sleep disturbance.
Classification of insomnia is
- Primary insomnia
- Idiopathic
- Psychophysiological: maladaptive conditions response to an acute
stressor when the bedroom is a place of heightened arousal
- Sleep state misperception: mismatch between the patient’s perceived
and actual sleep duration/quality
- Secondary insomnia
-
Poor sleep hygiene and behaviours
An active psychosocial stressor
A psychiatric disorder such as depression or anxiety
An abnormality of sleep causing arousal/awakening such as OSA, RLS,
chronic pain or hot flushes
- A medication such as a beta-blocker, or substance such as caffeine or
alcohol
Gabriella can’t sleep
List four (4) pieces of additional clinical
information that may assist in identifying the
cause(s) of Gabriella’s symptoms?
A thorough sleep history and clinical examination can assist in
identifying factors that may be contributing to Gabriella’s
symptoms. Important aspects of history taking in evaluating sleep
include:
-Comorbidities
-Medications
-Alcohol, caffeine and smoking history
-Occupation and current work hours
-Sleep hygiene including routine prior to sleep, sleep environment,
and sleep/wake cycle
-Consequences of poor sleep including feeling unrefreshed,
inattention,
poor
concentration,
lowered
mood
and
hypersomnolence
-Symptoms such as snoring, nocturnal awakenings, or abnormal leg
movements that suggest a sleep disorder
-Changes in weight
-Menopausal symptoms
-Symptoms of depression or anxiety
Important aspects of the physical examination are
determining:
-BMI
-Patency of nasal passages
-Presence or absence of retrognathia
-MMP score
Gabriella can’t sleep
Gabriella works day hours only. She exercises in the
evening and goes to bed at 10:30pm, but may take up to
an hour to fall asleep. She said she sleeps lightly and
wakes up 3-4 times during the night and has difficulty reinitiating sleep.
She wakes at 6am unrefreshed.
Gabriella’s husband has observed that she snores and has
occasional leg movements with no witnessed apnoeas.
Her last menstrual period was 4yrs ago and she continues
to experience vasomotor symptoms including hot flushes.
Her score on the ESS is 9/24. On examination, she has a
BMI of 28kg/m2, an MMP score of 1, no retrognathia and
clear nasal passages.
Gabriella can’t sleep
What investigations would you request?
Consider requesting the following investigations:
- FBC, UEC, TSH, ESR: to help exclude medical conditions
(anaemia, renal failure, thyroid disorder) and chronic
inflammatory disorders (rheumatoid arthritis and
sarcoidosis) that may contribute to symptoms
- A sleep diary – this can assist in evaluating sleep/wake
cycle and sleep hygiene.
- In laboratory polysomnography – this should be
considered if a specific sleep disorder such as OSA
needs to be excluded. Home-based sleep studies are
generally not recommended in patients like Gabriella
due to the complexity of the problem.
Gabriella can’t sleep
You request bloods, a sleep diary and sleep studies.
- All bloods are within normal limits
- Sleep diary – frequent caffeine use throughout
the day, strenuous exercise close to bedtime,
variable sleep/wake times with an average time
in bed of 7.5hrs. Sleep efficiency 89% with
average sleep duration 6.7hrs
- Sleep studies – total sleep time = 6hrs with
frequent brief awakenings. Intermittent snoring
with occasional hypopnoeas. Apnoea-hypopnoea
index of 14 events/hr, SaO2 >90%. There were no
periodic leg movements.
Gabriella can’t sleep
What is the cause (or causes) for Gabriella’s
symptoms?
Gabriella’s insomnia is likely to be multi-factorial in origin. The
sleep diary and efficiency suggest that suboptimal sleep
hygiene, circadian factors, sleep restriction and sleep state
misperception. Another factor affecting her sleep may be hot
flushes causing nocturnal awakenings. It is also suggested that
hormonal changes, which occur early during menopause, may
play a role in promoting sleep disturbance.
Nocturnal awakenings and awareness of those awakenings are
common in older individuals and may not represent significant
sleep pathology. The problem may not necessarily be the
awakening itself, but the individual’s response to it
(frustration/anxiety).
Although there is evidence of mild sleep disordered breathing,
in the setting of her clinical history there is more likely to be
an incidental finding of no clinical significance and may
therefore not require further treatment.
Gabriella can’t sleep
How would you manage Gabriella’s symptoms?
Gabriella’s symptoms could be managed by:
- Addressing her frustrations and misperceptions
- Teaching her strategies to assist in coping with difficulties in
getting to sleep and the difficulties in re-initiating sleep following
nocturnal awakenings
- Focusing on the sleep environment and removing distractions
including clocks, radios, televisions to address the circadian cycle
Circadian rhythm training involves managing the sleep/wake
cycle. Setting a fixed waking time and using techniques such as
sleep restriction may be affective.
Benzodiazepines should be avoided and although they are often
prescribed they don’t address the main issues, have significant
affects on sleep architecture and often exacerbate daytime
sleepiness and can lead to dependence and rebound insomnia.
It is important to work closely with a patient such as
Gabriella and to emphasise that there is no quick fix for
most presentations of insomnia. The aim is to achieve
gradual improvement over time. Patient compliance is
crucial to achieve optimal results. In treatment-resistant
patients, consider referral to a psychologist with
expertise in providing cognitive behavioural therapy for
insomnia.
www.nps.org.au has useful resources/information
discussing insomnia
The American Academy of Sleep Medicine also has a
range of clinical practice guidelines on a range of sleep
disorders. www.aasmnet.org